Headaches due to Nasal and Paranasal Sinus Disease.

Headache and rhinosinusitis are 2 of the most common conditions seen in clinical practice. Consider sinusitis in those with new-onset headache, along with nasal congestion, maxillary tooth discomfort, anosmia, cough, or fever. Most chronic and recurring headaches, especially if migraine features are present, are not due to sinus disease, with the possible exception of rhinogenic headache due to nasal contact points. Nasal endoscopy and neuroimaging with computed tomography or MRI can confirm diagnosis and guide treatment with antibiotics, adjuvant therapies and surgery.

Dental Pathophysiology of Odontogenic Sinusitis: Oral Surgical Complications.

The article explores the understudied pathophysiology of odontogenic sinusitis (ODS) development as a result of oral surgical complications such as oroantral communication (OAC) or fistula (OAF), maxillary sinus bone grafting, and dental implantation. A temporary OAC presents most often after dental extraction, especially with posterior maxillary teeth, though can happen with any oral surgical intervention. Maxillary sinus augmentation can also cause ODS, and while the pathophysiology is incompletely understood, it may be related to OAC/OAF formation or bone graft infection. Dental implants may also lead to ODS either via displacement into the sinus, partial protrusion into the sinus, or peri-implantitis.

Orbital preservation in the treatment of acute invasive fungal sinusitis.

Acute invasive fungal sinusitis (AIFS) is an aggressive disease with significant mortality and morbidity. Surgical debridement is a mainstay of treatment. However, orbital involvement may limit its efficacy and is an independent risk factor for mortality. Traditionally, orbital exenteration has been utilized in cases with orbital invasion and ophthalmoplegia or vision loss. Retrobulbar liposomal amphotericin B injection may improve disease control and has the potential to spare the morbidity associated with exenteration. In this video article, we document the use of serial endonasal debridement with retrobulbar injections to salvage the eye in a patient with significant orbital involvement. A 28-year-old immunocompromised female patient presented with acute onset restricted right extraocular movement, progressive orbital pain, V2 trigeminal numbness, and 20/40 vision. The patient underwent recurrent debridement and retrobulbar injections of liposomal amphotericin B. Her serial exams, including changes in extraocular muscle appearance and gradual improvement in extraocular movement, were documented. The exam six months after initial presentation demonstrated 20/20 vision, minimal extraocular movement restriction, and proper healing of the orbit and ethmoid. The salvage of the patient's orbit suggests that liposomal amphotericin B injections with debridement may be a viable treatment alternative in patients with acute invasive fungal sinusitis and orbital involvement.

Unilateral Sinus Disease: What Is, and Is Not Odontogenic Sinusitis?

The differential diagnosis of unilateral sinus disease (USD) is broad, and while concerning etiologies like sinonasal neoplasia, invasive fungal sinusitis, and cerebrospinal fluid rhinorrhea should always be considered, most cases are due to noninvasive inflammatory or infectious conditions. To diagnose USD appropriately, clinicians must integrate the clinical history and examination, nasal endoscopy, computed tomography (CT), and possibly MRI. Odontogenic sinusitis (ODS) is the most common cause of unilateral maxillary sinus opacification on CT, with 45% to 75% of such cases being odontogenic in nature. This study provides USD diagnostic considerations and reinforces the diagnostic approach to ODS.

Comparative Effectiveness of Dupilumab Versus Sinus Surgery for Chronic Rhinosinusitis With Polyps: Systematic Review and a Meta-Analysis.

BACKGROUND: Current treatment paradigms recommend surgical intervention when conventional medical management proves ineffective in resolving chronic rhinosinusitis with nasal polyposis. OBJECTIVES: To assess and compare the efficacy of dupilumab and functional endoscopic sinus surgery (FESS) for the treatment of chronic rhinosinusitis with nasal polyp (CRSwNP) over time. METHODS: Studies comparing CRSwNP patients who received dupilumab with those who underwent FESS were included. Outcome measures included the nasal congestion score (NCS), Sino-nasal Outcome Test-22 (SNOT-22), University of Pennsylvania Smell Identification Test-40 (UPSIT-40), and nasal polyp score (NPS). The risk of bias was evaluated using the Newcastle-Ottawa Scale. RESULTS: A total of 4 studies with 724 participants were included. The dupilumab group had a superior NCS, but an inferior NPS, compared to the FESS group during the follow-up period. The SNOT-22 score of the dupilumab group was inferior to that of the FESS group until 6 months posttreatment, but the scores were similar at around 1 year. A similar trend was observed for the UPSIT-40 score, but the score of the dupilumab group was higher at around 1 year. CONCLUSION: Functional endoscopic sinus surgery was more effective than dupilumab for several months after treatment. However, at 1 year after treatment, the effects of the 2 treatments became similar, with greater olfactory improvement seen in the dupilumab group.

Pneumocephalus: A Rare Complication of Sinusitis in a Pediatric Patient.

Pneumocephalus is uncommon, mostly arising as a result of surgery, trauma, infection, or neoplasm. Spontaneous occurrence is extremely rare and few case studies have been published. Pneumocephalus may also present as a complication of sinusitis and is a potential emergency. It is necessary to make a prompt diagnosis in order to direct treatment toward the underlying cause. Although usually asymptomatic, pneumocephalus can lead to tension pneumocephalus or septic meningitis as the result of infection from bacteria. We present a case of spontaneous, non-traumatic pneumocephalus in the setting of pansinusitis in a pediatric patient. Our aim is to briefly discuss the etiology and emergency department evaluation and management of patients with pneumocephalus.

Frontal Sinus Mucopyocele Presenting as a Painful Subcutaneous Forehead Mass in a Patient with Chronic Sinusitis.

Mucoceles of the paranasal sinuses are benign, expansile lesions that develop secondary to sinus ostia obstruction. Presenting signs and symptoms vary widely but frequently include frontal headache and swelling, as well as visual changes and globe displacement depending on orbital involvement in the case of frontal sinus mucoceles. Given the potential for orbital or intracranial involvement, urgent imaging with computed tomography (CT) is important for patients with symptoms concerning for a frontal sinus mucocele. Definitive treatment is surgical. In this article, we report a case of a 50-year-old male who presented to a primary care clinic with a painful forehead mass, found to have a frontal sinus mucocele with erosion through the frontal bone that was eventually treated surgically. We also summarize presenting signs and symptoms of frontal mucoceles reported in the literature as these are important for clinicians to be familiar with, considering the potential emergent complications.

Maxillary Antrostomy Versus Complete Sinus Surgery for Odontogenic Sinusitis With Frontal Sinus Extension.

OBJECTIVES: Endoscopic sinus surgery (ESS) is often necessary when managing odontogenic sinusitis (ODS), but ESS extent for ODS with extramaxillary sinus involvement has been incompletely studied. This study compared outcomes after wide maxillary antrostomy (MA) alone versus complete ESS for ODS with frontal sinus involvement. METHODS: A multicenter prospective cohort study was conducted on patients with uncomplicated ODS (no extrasinus spread) who underwent ESS when computed tomography demonstrated maxillary, anterior ethmoid (AE), and frontal sinus opacification. Multiple preoperative and postoperative variables were recorded, including 22-item sinonasal outcome tests (SNOT-22) and endoscopic findings. Ultimate SNOT-22 and endoscopic resolution, and time to SNOT-22 and endoscopic resolution were compared between patients who underwent MA alone versus "complete" ESS (maxillary, ethmoid, frontal; not sphenoid). RESULTS: Of 70 patients, mean age was 59.2 years, and 55.7% were male. Thirty-five underwent MA alone, and 35 had complete ESS. At first postoperative visits (mean 9.3 days), AE sinus purulence was more likely resolved after complete ESS compared with MA (97.1% vs. 71.4%, p = 0.006). However, time to resolution of AE purulence was comparable by 6 weeks postoperatively (p = 0.158). There were no significant differences in times to foul smell resolution and achieving ≥9 point SNOT-22 reduction (p > 0.05). CONCLUSIONS: For ODS with frontal sinus involvement, MA alone and complete ESS both resulted in rapid and long-term symptomatic resolution. While ultimate resolution of sinus purulence was equivalent between surgery groups, complete ESS did lead to faster resolution of frontoethmoidal purulence in a significant number of cases. LEVEL OF EVIDENCE: 2 Laryngoscope, 2024.

Occurrence of acute otitis and sinusitis in patients hospitalized for influenza.

Introduction: Acute otitis and sinusitis are common complications in patients with influenza and are responsible for increased hospitalization rates. Methods: A five-year retrospective study (2018-2023) was conducted including all patients hospitalized for influenza (etiologic diagnosis by RT-PCR) to identify the incidence and characteristics of cases complicated with otitis and/or sinusitis. Cases associated with other viral co-infections were excluded from the analysis. Results: We identified a cumulative rate of 20.6% (324 cases) of acute otitis (AO) and acute sinusitis (AS) among patients with influenza. Of these, 62.3% had AO, 28.1% AS, and 9.6% concomitant AO and AS. Cases of AO were predominant in the pediatric population (97.0%), while cases of AS were more common in adults (56.1%). Influenza A viruses were identified in 67.2% of patients. The infection with influenza B viruses increased the risk of acute congestive otitis media 2.1-fold (p=0.020), and influenza A viruses increased the risk of acute maxillary sinusitis 2.7-fold (p=0.029). Late presentation to the hospital, with a median of 4 days from the onset of influenza symptoms, was identified as a factor in the occurrence of AO and AS. Conclusions: The risk of AO and AS is increased in patients with influenza, especially in the pediatric population and in late hospital presentations. These findings highlight the importance of proper monitoring and management of patients with influenza to prevent the development of complications, as well as the need to better understand the mechanisms whereby influenza viruses contribute to these secondary conditions.

[Intracranial epidural abscess associated to sinusitis with positive response to medical treatment]. / Absceso epidural intracraneal asociado a sinusitis con respuesta al tratamiento médico.

Epidural abscesses are rare intracranial infections. They can occur from neurosurgical procedures, or head and neck infections. Successful treatment usually requires a combination of drainage procedure and antibiotic therapy. We present the case of a young patient with an intracranial epidural abscess and meningitis secondary to sinusitis who received only corticosteroids and antibiotic therapy, with good evolution.

Los abscesos epidurales son infecciones intracraneales de baja frecuencia. Pueden ocurrir derivados de procedimientos neuroquirúrgicos, o infecciones de cabeza y cuello. El tratamiento exitoso generalmente requiere la combinación de un procedimiento de drenaje y antibioticoterapia. Se presenta el caso de un paciente joven, con un absceso epidural intracraneal y meningitis, secundario a sinusitis que recibió solo tratamiento con corticoides y antibioticoterapia con buena evolución.

Subperiosteal abscess volume; an objective indication for surgical management in pediatrics.

PURPOSE: Subperiosteal abscess (SPA) can lead to devastating morbidity and mortality. Prompt management is important; however, the choice of management route is controversial. This study investigates factors associated with surgical management and defines a cut-off abscess volume prompting surgical intervention. METHODS: SPA cases presented to King Saud University Medical City (KSUMC) from 2014 to 2023 were reviewed. The surgical approach was studied in association with factors including age, gender, symptoms and signs, laboratory results, computed tomography (CT) characteristics, medications, and surgical approach. Multiple statistical tests were used for analysis, including student t-test, chi-square, multiple logistic regression analysis, and receiver operating characteristic (ROC) analysis. RESULTS: Patients were managed medically (n = 14, 45.16%) or surgically (n = 17, 54.84%). The average duration of antibiotics was 15 days. Superior SPA favors surgical management (OR = 6.722, CI [1.332-33.913], p = 0.029), along with the use of steroids (OR = 5.625, CI [0.915-34.572], p = 0.049), and abscess volume (OR = 10.003, CI [1.418-70.540], p < 0.001). However, the only factor attributing to a surgical decision on multivariate logistic regression analysis was abscess volume (OR = 5.126, CI [1.023-25.694], p = 0.047). SPA volume of ≥ 0.648 ml strongly prompts surgical management, with a sensitivity of 94.1% and a specificity of 71.4% (p = 0.000). CONCLUSION: SPA volume increases the likelihood of surgical intervention by five times, especially when abscess volume is ≥ 0.648 ml.

Acute Streptococcus pneumoniae Meningitis: A Case Report.

A 69-year-old woman without significant medical history presented to an emergency department for evaluation and management of altered mental status and a 10-day history of worsening symptoms of upper respiratory infection. Two days previously, she had been evaluated at an urgent care center, where she reported productive cough and neck pain. Evaluation in the emergency department aroused suspicions of sepsis and meningitis, and computed tomography of the head revealed nontraumatic pneumocephalus with evidence of bony erosion of the sinus into the brain. Culture results revealed disseminated Streptococcus pneumoniae. Cerebral vasculopathy secondary to the meningitis caused bilateral acute ischemic strokes in areas of the brain, with the potential to lead to significant disability.

Dental Evaluation: Oral Surgery-Related Complications.

The article provides an in-depth review focused on diagnosing oral surgery-related complications that may cause odontogenic sinusitis (ODS). It emphasizes the importance of evaluating patients with prior oral surgical procedures to determine whether the prior procedure is an ongoing infectious source of the ODS. Specifically, diagnostic evaluations will be described for detecting oroantral communications and fistulas, dental implant dislocation or protrusion, and whether implants and graft placed in maxillary sinuses are infected. It highlights the role of different oral examination techniques, optimal imaging modalities, and the importance of otolaryngologic collaboration to evaluate for infectious ODS.

Management of Endodontic Disease for Odontogenic Sinusitis.

Primary dental treatments for odontogenic sinusitis (ODS) due to endodontic infections (pulpal necrosis and apical periodontitis ± periapical abscess) include extraction and root canal treatment (RCT). Published evidence is lacking on the success of primary endodontic treatment for purulent ODS, with the majority of RCT-related series reporting on its success at resolving reactive maxillary sinus mucositis. Dental extraction is the most definitive treatment of endodontic disease causing ODS, but compromises the functional dentition and still often fails to resolve the purulent sinusitis. This article highlights key concepts of RCT and dental extraction techniques, as well as their published success at resolving ODS.

Surgical Drainage and Simultaneous Sinus Floor Augmentation in Patients with Chronic Maxillary Sinusitis.

Chronic maxillary sinusitis accompanied by severe thickening of the sinus mucosa, blockage of the ostium, and patient-reported symptoms requires preoperative assessment and treatment by an otolaryngologist before maxillary sinus floor augmentation (MSFA). Prescription of antibiotics and nasal saline irrigation are the first choice of treatment; however, endoscopic sinus surgery is considered when the treatment's effect is limited and drug resistance is observed. Nevertheless, MSFA performed in the presence of sinus pathologies have been reported to have favorable results when the lesions are managed properly. This report presents cases of two patients who required MSFA but were diagnosed with chronic maxillary sinusitis (case 1 with nasal sinusitis and case 2 with dental sinusitis). After 2 weeks of antibiotic therapy, endoscopic surgery was recommended due to minimal changes in the size of the sinus lesion; however, the patients refused because of improved self-reported symptoms. Therefore, intraoral surgical drainage was planned as an alternative treatment. A large bony window was prepared at the lateral wall of the maxillary sinus, and a long intentional incision was made to improve access for the suction tip in various directions and depths into the sinus cavity. Thorough suction of the purulent exudate and saline irrigation were performed through this access. The size of the perforated area was reduced along with the elevation of the Schneiderian membrane from the sinus floor, and simultaneous bone grafting with implant placement was performed. Prosthesis was delivered after 6-8 months. At 1-year follow-up after loading, favorable outcomes of implant survival and maintenance of augmented bone height were observed, with no recurrence of postoperative sinusitis. Within the limitations of the present case report, thorough sinus drainage and saline irrigation during maxillary sinus floor augmentation resolved sinus infection in patients with chronic maxillary sinusitis with short-term clinical outcomes.

Factors Impacting Outcome and Prognosis of Invasive Fungal Sinusitis: How Vital is Iron Metabolism?

Iron is an important micronutrient involved in cell biology through vital reactions. We examined the correlations between iron metabolism parameters and the course of invasive fungal sinusitis. Patients with invasive fungal sinusitis were enrolled. Serum iron and ferritin levels, total iron-binding capacity, and transferrin saturation were measured at the initiation of treatment. Patients were followed for 6 months, and the clinical course was categorised as improvement or worsening/death. A total of 35 patients were enrolled. The average ferritin levels in mucormycosis patients was 944.9 ng/ml, versus 110.7 ng/ml for aspergillosis patients. Iron levels were significantly lower in mucormycosis than in aspergillosis (29.14 µg/dl vs. 68.55 µg/dl). Total iron-binding capacity was significantly different between the two groups (16.76 µg/dl vs. 330.36 µg/dl). After 6 months, improvement, worsening, and death were noted for 18, 8, and 9 patients, respectively. Higher iron levels and lower ferritin levels were linked with improvement. Total iron-binding capacity was significantly higher in improved patients (2314 vs. 151). Iron metabolism parameters play significant roles in the preemptive judgment of the course of fungal sinusitis. Based on these findings, studies on drugs affecting iron metabolism should be conducted.

Computed Tomographic Study of Frontal Sinus Cells and Opacification as Per the International Frontal Sinus Anatomy Classification.

INTRODUCTION: International frontal sinus anatomy classification (IFAC) was introduced in 2016 to standardize the nomenclature of the cells in the frontal recess region, facilitate better communication between surgeons and precision in surgical planning, and improve surgical teaching. This study aims to estimate the radiological prevalence of the different frontal recess cells according to the IFAC and to evaluate the relationship of these cells with the frontal sinus opacification in patients with chronic rhinosinusitis. METHODS: In this study, 90 participants diagnosed with chronic rhinosinusitis (CRS) who underwent computed tomogram (CT) of the para nasal sinuses were enrolled consecutively. The CT images were were studied in detail using RadiAnt DICOM viewer. The frontal recess cells were grouped as per the IFAC guidelines and their respective prevalence was calculated. The frontal recess cells were grouped as per the Opacification or mucosal thickening within these cells and the frontal sinuses were noted. A multivariate logistic regression analysis was done to evaluate the association between frontal sinus opacification and presence of various IFAC cells. RESULTS: A total of 640 IFAC cells were documented in 180 sides, of which 326 were anterior cells, 263 were posterior cells and 51 were medial cells. The most prevalent cell was the agger nasi cells(ANC), present in 91.7% of 180 sides, the supra agger nasi cells(SANC), Supra agger nasi frontal cells(SAFC), supra bulla cells(SBC), supra bulla frontal cells(SBFC), supra orbital ethmoidal cells(SOEC) and frontal septal cells(FSC) were present in 47.8%,37.8%, 65.6%,28.9%, 51.1% and 28.3% respectively. There was no significant association of presence of IFAC cells and frontal sinus opacification except for SBFC(p = 0.038). A significantly higher number of diseased frontal recess cells were seen with involved frontal sinuses when compared with non-involved frontal sinuses across all types of IFAC cells. CONCLUSION: The ANC were the most prevalent among all the IFAC cells and the FSC were the least prevalent. There was no significant association with the presence of different types of IFAC cells and frontal sinus opacification except for SBFC. However, there was a significantly higher number of diseased IFAC cells associated with frontal sinus opacification than in those without frontal sinus opacification.

Healthcare resource use and costs associated with the misdiagnosis of migraine.

OBJECTIVE: To compare healthcare resource utilization and healthcare costs in patients with migraine with or without a history of misdiagnosis. BACKGROUND: Despite the high prevalence of migraine, migraine is commonly misdiagnosed. The healthcare resource use and cost burden of a misdiagnosis is unknown. METHODS: This retrospective cohort study identified adults with an incident migraine diagnosis from the Merative™ Marketscan® Commercial and Medicare Supplemental Databases between June 2018 and 2019. Patients with a diagnosis of commonly considered misdiagnoses (headache, sinusitis, or cervical pain) before their migraine diagnosis were classified as the "misdiagnosed cohort." Patients in the misdiagnosed cohort were potentially misdiagnosed, then eventually received a correct diagnosis. Patients without a history of commonly considered misdiagnoses prior to their migraine diagnosis were classified as the "correctly diagnosed cohort." Healthcare resource utilization and healthcare costs were assessed in the period before migraine diagnosis and compared between the cohorts. Outcomes were reported as per patient per month and compared with incidence rate ratios. RESULTS: A total of 29,147 patients comprised the correctly diagnosed cohort and 3841 patients comprised the misdiagnosed cohort and met the inclusion criteria. Patients in the misdiagnosed cohort had statistically significantly higher rates of inpatient admissions (0.02 vs. 0.01, incidence rate ratio [IRR] 1.61, 95% confidence interval [CI] 1.47-1.74), emergency department visits (0.10 vs. 0.05; IRR 1.89, 95% CI 1.79-1.99), neurologist visits (0.12 vs. 0.02; IRR 5.95, 95% CI 5.40-6.57), non-neurologist outpatient visits (2.64 vs. 1.58; IRR 1.67, 95% CI 1.62-1.72) and prescription fills (2.82 vs. 1.84; IRR 1.53, 95% CI 1.48-1.58) compared to correctly diagnosed patients. Misdiagnosed patients had statistically significantly higher rates of healthcare cost accrual for inpatient admissions ($1362 vs. $518; IRR 2.62, 95% CI 2.50-2.75), emergency department visits ($222 vs. $98; IRR 2.27, 95% CI 2.18-2.36), neurologist visits ($42 vs. $9; IRR 4.39, 95% CI 4.00-4.79), non-neurologist outpatient visits ($1327 vs. $641; IRR 2.07, 95% CI 1.91-2.24), and prescription fills ($305 vs. $215; IRR 1.41, 95% CI 1.18-1.70) compared to correctly diagnosed patients. CONCLUSION: Patients with migraine who have a history of misdiagnoses have higher rates of healthcare resource utilization and cost accrual versus those without such history.

A Rare Neonatal Infection: Methicillin-Resistant Staphylococcus aureus (MRSA) Orbital Cellulitis.

We present a case of orbital cellulitis as a rare cause of late-onset neonatal sepsis in a 4-week-old infant. Although ample literature describes orbital cellulitis in pediatric age groups, community-acquired orbital cellulitis as a cause of late-onset neonatal sepsis has not been well-described. We report one case of late neonatal sepsis in which orbital cellulitis and subsequent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia were found. This case emphasizes the importance of early recognition of orbital cellulitis in neonates and awareness of this unique cause of sepsis.

Predictors for Development of Chronic Rhinosinusitis in Transplant Recipients.

OBJECTIVES: Studies suggest that transplant patients are at a higher risk of developing chronic rhinosinusitis (CRS). However, there is a dearth of studies describing the factors that may be linked to the development of CRS in this population. Our objective is to identify the risk factors associated with the development of CRS in transplant recipients. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary care center. METHODS: This cohort included 3347 transplant recipients seen between 2017 and 2022. Of these, 2128 patients met the inclusion criteria and were grouped according to whether they were diagnosed with CRS during the post-transplant period. The analysis included both univariate and multivariate analysis to ascertain the odds ratio (OR) and predictive factors. RESULTS: Of the 2128 patients, 649/2128 (30.4%) had CRS. CRS patients had an increased prevalence of previous endoscopic sinus surgery, allergic rhinitis, and recurrent acute rhinosinusitis in the pre-transplant period compared to the non-CRS group. According to the multivariate analysis, patients with primary immunodeficiency and additional transplant were 1.9 and 3.1 times more likely to develop CRS during the posttransplant period (95% CI: 1.3-2.6, p < .0001), (95% CI: 1.3 -7.3, p = .01), respectively. Sirolimus use was also associated with the development of CRS (OR = 1.4, 95% CI: 1.1-1.9, p = .01). CONCLUSION: This study is the largest cohort aimed at determining the predictive factors associated with the development of CRS. Patients with pretransplant rhinologic conditions, hematologic deficiencies, and the utilization of specific immunosuppressants were found to have a higher likelihood of developing CRS following transplantation.